UC-NRLF 


B    5    AMb    2b^ 


IMPLANTA  TION  OF  TEETH 


WILLIAM  J.  YOUNGER,  M.  D. 


Individual  Report 

of  the 

Committee  of  Pathology  and  Surgery, 

read  before  the 

California  State  Dental  Association, 

Inly  21,  1886, 

at  San  Francisco. 


77?  ^6^CJ/t/l-lt,\ 


IM-te'ttVJ. 


IMPLANTATION  OF  TEETH 


sr 


WILLIAM  J.   YOUNGER,  M.  D. 

Ex-President   of  the    California    State   Dental  Association; 

Ex-President   San   Francisco   Dental  Association; 

Member  California  State  Medical  Society; 

Member  San  Francisco  County  Medical  Society. 


INDIVIDUAL   REPORT  of  the  COMMITTEE  of  PATHOLOGY  and  SURGERY 

read  before  the 

CALIFORNIA   STATE  DENTAL  ASSOCIATION, 

July  21,  1886. 


SAN  FRANCISCO: 

Wm.  S.  Duncombe  <Sr»  Co.,  Publishers 

2ii  Post  Street. 


|OAN  STACK 
GTFT 


V   ffQ 


IMPLANTATION  OF  TEETH 


Mr.  President  and  Gentlemen — 

Dr.  "Warner,  Chairman  of  the  Committee  on  Surgery  and 
Pathology,  did  me  the  honor  to  say,  to-day,  that  the  only  new 
thing  in  Dental  Surgery,  that  he  was  aware  of,  was  the  suc- 
cessful transplantation  of  teeth  into  artificial  sockets  by  Dr. 
Younger,  one  of  the  Committee;  several  of  which  operations 
had  been  witnessed  by  himself,  and  the  success  of  which  he 
could  vouch  for.  He,  therefore,  delegated  to  Dr.  Younger  the 
task  of  making  out  the  report  of  the  Committee.  Had  Dr. 
Warner  informed  me  of  this  intention  sooner,  I  should  have  been 
able  to  present  to  you  a  report  fuller  in  detail  and  more  free  from 
crudities  than  this,  of  necessity,  must  be. 

Transplantation  and  Implantation,  as  I  call  my  new  operation, 
has  so  far  realized  my  most  sanguine  expectations,  and  leads  me 
to  the  belief  that  in  a  short  while  it  will  become  as  firmly  estab- 


318 


lished  in  professional  practice  as  any  other  operation  requiring 
skill  and  judgment. 

Since  the  publication  of  my  brochure  on  "  Transplantation  of 
Teeth  into  Natural  and  Artificial  Sockets,"  which  you  have  all 
seen,  and  a  portion  of  which  formed  a  report  made  to  this  Associa- 
tion, at  its  last  session,  I  have  made  a  discovery  in  regard  to  the 
vitality  of  the  pericementum,  that  is  even  more  startling  than  the 
success  of  the  operation  of  Implantation  itself.  In  the  pamphlet 
I  recommended  the  use  of  cock's  combs  as  a  means  of  pre- 
serving the  vitality  of  the  peridental  membrane,  and  also  men- 
tioned that  in  two  instances  the  life  of  this  membrane  had  been 
preserved  for  over  fifty  hours,  in  tepid  water.  I  now,  however, 
have  to  report  a  case — one  of  several — which  proves  that  these 
means  are  not  at  all  necessary  to  preserve  the  vitality  of  this,  the 
most  wonderful  tissue  in  the  human  body;  that  this  vitality  of  the 
pericementum  is  marvelous;  and  that  it  may  be  as  tenacious  as 
that  inherent  in  the  seeds  of  plants. 

In  the  early  part  of  March,  1886,  Mrs.  Dr.  H.  G.  Blankman— the 
wife  of  one  of  the  pioneer  dentists  of  this  coast — brought  me  a 
bicuspid  that  had  been  extracted  at  her  solicitation,  in  Sacramento, 
on  the  31st  day  of  January,  1885,  in  the  belief  that  it  was  the  seat 
of  a  neuralgic  pain,  which  had  been  the  cause  of  great  anguish  to 
her.  This  tooth,  brought  to  me  after  this  long  lapse  of  time,  had 
in  the  meanwhile  been  carried  about  in  her  portemonnaie,  stowed 
away  in  her  jewel  case  and  shuffled  about  in  her  bureau  drawer. 
And  this  tooth   she  wanted   replanted  in  her  jaw!      My  first 


—  5  — 

impulse  was  to  laugh,  my  next  to  argue  with  her  about  the 
impossibility  of  success  of  such  an  operation,  explaining  to  her 
that  it  was  due  only  to  the  vitality  of  the  membrane  covering  of 
the  root  that  the  operation  owed  its  success;  that,  without 
this  living  membrane,  the  tooth  was  as  impossible  of  attach- 
ment as  so  much  bare  ivory  or  porcelain;  and  that  while  I  had 
succeeded  in  keeping  this  membrane  alive  for  over  two  days,  it 
was  by  constant  immersion  in  warm  water,  at  a  blood  tempera- 
ture: but  that  the  pericementum  of  this  tooth  was,  as  she 
herself  could  see,  as  dry  and  shriveled  as  parchment,  and  as 
devoid  of  life. 

Just  as  I  had  persuaded  her  of  the  impossibility  of  success, 
there  flashed  through  my  mind  a  passage  in  John  Bell's  work  on 
the  "  Anatomy  and  Physiology  of  the  Human  Body/'  that  I  had 
lately  read,  which  awoke  the  suggestion  that  success  in  implant- 
ing that  tooth  was,  after  all,  possible. 

This  eminent  surgeon,  in  criticising  an  article  of  the  famous 
John  Hunter,  says:  "How  can  such  vitality  exist  independently 
of  a  circulation?  But  there  are  not  wanting  examples  of  an 
obscure  and  low  degree  of  life  existing  in  animals'  ova,  or 
seeds,  for  seasons  without  a-  circulation;  and  if  for  seasons,  why 
not  for  a  term  of  life?" 

While  this  passage  did  not  bear  directly  on  the  subject  in 
question,  it  somehow  awoke  a  train  of  thought  that  led  me 
to  the  conclusion,  that  in  that  dry,  shriveled  membrane  there 


—  6  — 

possibly  lay  lurking  a  dormant  life,  which  under  favorable  condi- 
tions would  rouse  its  energies  and  make  the  tooth  enclosed  once 
more  a  living,  useful  organ. 

I  had  proved  that  the  peridental  membrane  possesses  a  won- 
derful tenacity  of  life,  in  at  least  two  instances,  where,  after  it 
had  been  removed  from  all  life-giving  connection  for  fifty-two 
hours,  it  was  as  vigorous  in  forming  attachments  as  though  it 
had  been  planted  immediately  after  removal.  I  therefore  reas- 
oned with  myself,  if  this  peridental  membrane  preserves  a  vital- 
ity unimpaired  for  fifty-two  hours,  why  not  for  so  many  weeks 
or  months?  So  I  said:  "Mrs.  Blankman,  the  idea  has  just 
occurred  to  me  that  what  you  want  done  is,  perhaps,  possible." 
And  I  explained  the  cause  of  this  revolution  of  opinion,  as  she  is 
not  only  a  brave  but  a  very  intelligent  woman;  and  continuing, 
said :  "  I  will  perform  this  operation  as  an  experiment,  to  test  the 
vitality  of  the  pericementum;  for,  though  I  have  no  positive 
expectation,  I  have  a  hope  of  its  success."  So,  on  the  11th  of 
last  March,  in  the  presence  of  and  with  the  assistance  of  Dr. 
Alexander  Warner,  who  was  acquainted  with  all  the  circum- 
stances of  the  case,  I  drilled  a  socket  between  the  first  left 
superior  bicuspid  and  first  molar;  and  after  soaking  the  tooth 
in  water — temperature  120°  Fah. — for  twenty-five  minutes,  to 
soften  the  membrane,  restored  to  the  jaw  that  which  it  had 
been  deprived  of  just  thirteen  months  and  eleven  days  before. 

As  the  dental  aspect  of  the  tooth  was  perfect,  and  the  approx- 
imal  not  nearly  so  much  so,  I  turned  the  tooth,  thereby  much 


—  7  — 

improving  the  original  appearance  of  that  portion  of  the  mouth. 
When  the  operation  was  finished,  the  tooth  was  found  so  firmly 
fixed  in  the  socket  that  retaining  ligatures  were  not  applied : 
and  union  took  place  as  rapidly  and  as  thoroughly  as  if  it  had 
been  a  fresh  tooth. 

The  tooth  retaining  this  firmness,  and  no  swelling  nor  pain 
ensuing,  the  lady  commenced  eating  with  it,  and  at  the  end  of 
twelve  days  became  so  careless  in  her  use  of  the  tooth,  that  she 
bit  a  hard  crust  of  French  bread  with  it.  This  was  too  much; 
the  tooth  received  a  wrench  that  loosened  it  and  caused  the 
gum  to  bleed  profusely.  Next  morning  she  hurried  to  the  office, 
and  with  tears  in  her  eyes,  narrated  the  accident.  I  found  the 
tooth  quite  loose,  but  not  dropping,  and  the  gum  on  the  pala- 
tine surface  swollen,  and  with  the  evidence  of  having  bled  at  the 
margin. 

In  my  heart  I  was  glad  the  accident  had  happened;  for  to  me 
it  was  a  test  of  the  question  whether  the  retention  of  the  tooth 
was  due  simply  to  the  nice  adaptation  of  the  walls  of  the  socket 
to  the  root  of  the  tooth,  and  therefore  only  mechanical,  or 
whether  it  was  really  due  to  awakened  life  in  the  peridental 
membrane,  and  cbnsequent  vital  connection  with  the  living  en- 
vironment of  gum  and  alveolar  substance. 

If  mechanical,  I  argued,  the  irritation  that  has  been  set  up 
around  it,  especially  in  its  present  loose  condition,  will  cause  its 
expulsion;  but  if  vital,  it  will  be  retained  and  become  firm  again. 
I  therefore  did  not  seek  to  retain  it  in  place  by  any  ligature,  but 


—  8  — 

simply  painted  the  gum  with  tincture  of  iodine,  and  cautioned 
her  not  to  chew  on  that  side  until  I  gave  her  permission.  In  one 
week  all  marks  of  the  accident  had  passed  away;  the  tooth  be- 
came again  firmly  fixed,  and  remains  to  the  present  moment  as 
solid  as  a  rock.  I  have  tried,  since  then,  to  pass  a  delicate  instru- 
ment, the  point  of  which  had  been  flattened  for  the  purpose,  be- 
tween the  gum  and  the  tooth;  but  the  act  gave  as  much  pain,  and 
the  instrument  met  with  as  much  resistance,  as  in  the  tissues  sur- 
rounding the  teeth  that  had  never  been  disturbed  in  their  sockets : 
all  of  which  clearly  proves  that  the  pericementum  of  that  tooth — 
dry  and  shriveled  as  it  was — had  during  those  long  months  of 
absence  from  any  life-supporting  substance,  tossed  about  from 
place  to  place,  from  pocket  and  purse  to  casket  and  drawer,  pre- 
served a  vitality  as  fresh  and  vigorous  as  when  it  was  removed 
from  the  place  in  which  it  grew. 

I  am  happy  to  say  that  Mrs.  Blankman  has  kindly  consented, 
in  the  interest  of  science,  to  present  herself  to  you  this  after- 
noon, in  order  that  you  may  examine  this  tooth,  and  satisfy 
yourselves  by  personal  and  thorough  examination,  as  to  the 
success  of  the  operation.  And  I  want  each  and  every  one  of 
you  gentlemen  to  test  in  every  way  that  your  ingenuity  may 
suggest — short  of  extraction — the  statement  I  have  made,  that 
vital  connection  has  been  established  between  that  tooth  and 
the  walls  of  the  socket,  as  perfect  as  that  of  the  other  teeth  that 
have  grown  there  and  never  been  tampered  with. 

I  have  since  tried  implanting  teeth  which  have  been  extracted 


—  9  — 

for  weeks  and  months,  with  equal  success,  proving  the  wonder- 
ful tenacity  of  life  in  the  peridental  membrane. 

The  question  now  in  my  mind  is:  "  When  does  the  pericemen- 
tum die?" 

In  consequence  of  these  experiments,  and  the  equal  success 
of  the  implantation  of  long  extracted  teeth  with  that  of  fresh 
ones,  I  have  discarded,  as  unnecessary,  the  warm  water  and  the 
comb  of  the  troublesome  cock. 

I  now  simply  lay  the  teeth  aside  in  a  clean,  cool,  dry  place, 
and  prepare  and  use  them  as  I  want  them. 

I  have  also  discarded  the  flat  drill,  and  use,  instead,  graded 
trephines  for  piercing  the  bone  and  for  doing  the  major  part  of 
the  work;  finishing  the  walls,  as  formerly,  with  burs  of  various 
shapes. 

Much  doubt  has  been  expressed  by  the  profession  in  the  East 
and  elsewhere  as  to  the  stability  of  implanted  teeth,  because  the 
kindred  operations  of  Keplantation  and  Transplantation  that  have 
come  under  their  observation,  and  which,  at  first,  gave  promise 
of  permanency,  have  so  generally  turned  out  failures  in  one  or 
two  years,  from  absorption  of  the  roots.  They  argue  that  if 
Replantation,  which  is  the  putting  back  of  a  tooth  into  the  socket 
from  which  it  has  been  but  just  drawn;  and  Transplantation, 
which  is  the  planting  of  a  stranger  tooth  into  a  socket  from 
which  its  own  has  been  but  freshly  extracted:  if,  they  say, 
these  cognate  operations,  where  the  conditions  seem  so  much 
more  favorable,  in  consequence  of  the  sockets  being  natural, 


—  IO  — 

are  so  generally  failures,  what  better  result  can  be  expected 
from  an  operation  where  the  socket  is  formed  by  violence  to  the 
jaw? 

Now,  if  they  would  but  consider  the  conditions  and  circum- 
stances under  which  these  different  operations  are  undertaken, 
they  would  readily  see  that  the  premises  upon  which  they 
ground  their  assumption  are  unsound  and  deceitful.  For  in- 
stance, in  replantation,  as  this  operation  is  usually  performed, 
the  parts — that  is,  the  peridental  membrane,  the  apex  of  the 
root  and  the  alveolar  process  immediately  surrounding  these — 
are  highly  inflamed,  in  a  state  of  disease,  with  pus  either 
already  formed  or  forming  at  the  end  of  the  root,  and  the  oper- 
ation is  undertaken  with  the  view  of  relieving  or  aborting  an 
alveolar  abscess.  A  portion  of  the  diseased  apex  is  then  cut 
off,  and  the  tooth  is  forced  back  into  the  cavity.  Here  we 
have  a  diseased  root  thrust  back  into  a  diseased  socket.  The 
disease  is  not  removed,  its  conditions  are  simply  modified; 
and  while  the  congestion  may  subside,  and  the  tooth  become 
comparatively  comfortable,  the  disintegration  of  the  root  sub- 
stance— already  begun — is  likely  to  continue,  and  in  the  course 
of  time  the  entire  root  becomes  destroyed,  or,  what  is  called 
absorbed;  and  the  bodiless  crown  drops  off.  So  much  for 
Eeplantation. 

Again,  in  Transplantation  there  is  a  healthy  tooth,  but  it  is 
usually  made  to  take  the  place  of  a  miserable,  old,  diseased 
root,  that    has    been  growling  and    festering  in    a    diseased 


—  II  — 

socket  for  years,  to  the  discomfort  of  its  unfortunate  possessor. 
The  diseased  root  is  pulled  out,  but  is  the  disease  in  the 
surrounding  alveolus  extracted  with  it  ?  On  the  contrary, 
enough  is  usually  left  in  its  tissue  to  make  war  upon  the 
new  occupant,  and  either  cause  its  expulsion,  or  eat  away  its 
substance.  You  must  remember,  that  while  the  old  root 
remained,  there  was  sufficient  vent  through  its  decayed  or 
broken  structure  to  permit  the  gases  of  decomposition  and  the 
pus  to  escape,  and  thus  prevent  active  trouble.  But  when  the 
new  tooth  is  put  in,  the  vent  is  entirely  occluded,  and  if  there 
be  sufficient  disease  in  the  alveolus,  the  retained  gases  and 
pus  effect  the  expulsion  or  the  painful  elongation  of  the  intruder. 
If  not  enough  disease  is  left  to  do  this,  then  the  slow  process  of 
erosion  is  apt  to  ensue,  and  the  root  becomes,  in  time,  absorbed. 

Now,  in  Implantation  we  have  a  healthy  root  in  a  healthy  socket; 
and,  therefore,  the  factors  that  tend  to  the  destruction  of  the  root 
in  Keplantation  and  Transplantation  are  not  present,  and,  there- 
fore, not  operative  in  Implantation. 

As  to  the  seeming  violence  to  the  bony  structure  of  the  jaw, 
I  will  state  that  there  is  no  substance  in  the  human  body  that 
seems  so  tolerant  of  abuse  as  this  same  alveolar  process.  And 
my  experience  is,  that  union  takes  place  more  readily  and  kindly, 
and  the  teeth  become  much  sooner  firm  and  serviceable  in  Im- 
plantation than  in  either  of  the  other  operations. 

I  trust,  my  brother  practitioners,  that  what  I  have  read  to  you 
will  serve  to  dispel  whatever  gloomy  forebodings  you  may  also 


—    12  

have  entertained,  in  considering  tl^e  future  of  Implantation, 
and  that  you  will  apply  yourselves  at  once  to  master  this  opera- 
tion, for  the  benefit  of  your  patients  and  of  yourselves.  Also,  I 
urge  on  you  the  practice  of  Eeplantation  and  Transplantation, 
for  they  can  be  made  uniformly  successful,  if  you  but  follow  the 
system  I  have  made  you  acquainted  with,  and  the  primal  rule 
of  which  is,  to  allow  no  disease  to  remain  in  socket  or  in  root. 
Do  not  wait  half  a  lifetime,  as  the  pessimists  in  the  profession 
would  have  you  do,  in  order  to  find  out  if  the  operation  is  going 
to  be  successful,  but  commence  now. 

In  this  paper  I  have  summarized  these  operations  as  per- 
formed by  our  Eastern  brethren,  in  order  to  make  their  argu- 
ment as  effective  as  possible,  and  so  to  impress  upon  you  the 
reason  of  the  failure  of  Replantation  and  Transplantation,  as 
practiced  by  them,  and  to  demonstrate  that  to  the  disease  left  in 
the  socket  and  root,  or  in  the  socket  alone,  must  be  attributed 
the  failures  caused  by  absorption  of  the  root;  otherwise,  why 
should  the  result  of  my  experience  in  these  operations  be  so 
different  from  theirs  ?  In  all  my  practice  of  these  kindred 
operations — and  it  has  probably  far  exceeded  that  of  any  other 
practitioner  in  the  United  States — I  have  had  but  one  case 
of  non-success,  due  to  the  absorption  of  the  root.  As  it  has  a 
lesson  in  point,  I  will  narrate  it. 

In  this  case,  the  tooth  inserted  was  but  poorly  covered  with 
pericementum,  and  the  socket  had  been  diseased  for  eighteen 
years,  and  was,  moreover,  so  much  larger  than  the  root  that  the 


—  13  — 

tooth  had  to  be  held  in  by  ligatures.  The  evening  after  its  in- 
sertion, the  ligature  loosened  and  the  tooth  fell  out  and  dropped 
on  the  carpet.  The  gentleman  placed  it  immediately  back  in  the 
socket,  and  being  unable  either  to  tie  it  or  find  me,  retained  it 
in  position  by  closing  his  jaw  and  keeping  his  teeth  tightly 
pressed  together  by  means  of  a  handkerchief  passed  under  his 
chin  and  tied  over  his  head.  At  nine  o'clock  the  next  morning 
I  found  that  attachment  had  already  taken  place,  which  assured 
me  that  it  had  not  been  fatally  injured  by  the  episode  of  the 
night  previous.  I  therefore  renewed  the  ligatures,  and  when 
the  gentlemen  started  for  his  English  home,  two  months  later, 
the  tooth  was  well  attached,  though  not  firm.  This  operation 
was  performed  March  2d,  1885;  and  a  letter,  dated  more  than  a 
year  later,  informed  me  that  the  crown  had  broken  off,  and  he 
was  puzzled  to  know  why  it  should  have  done  so,  when  he  was 
not  cracking  nuts  with  it!  He  also  wrote  that  the  fangs  re- 
mained imbedded;  but  in  this  he  must  be  mistaken.  It  is,  in 
my  mind,  a  case  of  absorption  of  the  roots. 

It  is  the  only  case  where  I  did  not  either  cut  out  the  disease 
nor  treat  it  sufficiently  long  to  satisfy  myself  that  it  was  all 
gone  from  the  socket;  and  it  is  the  only  tooth  I  have  lost  by 
absorption.  I  may  say  that  in  cases  like  this,  where  the  size  of 
the  socket  is  in  excess  of  the  diameter  of  the  root,  either  from 
natural  causes  or  alveolar  disease,  I  form  an  artificial  root  of  gum 
shellac,  of  the  shape  and  a  trifle  smaller  than  the  body  of  the 
root  to  be  inserted;  to  which  I  attach  an  artificial  crown.     This 


X 


